Healthcare Provider Details

I. General information

NPI: 1225769870
Provider Name (Legal Business Name): YUKON COMMUNITY RECOVER SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3932 E 8TH AVE
ANCHORAGE AK
99508
US

IV. Provider business mailing address

3924 E 8TH AVE
ANCHORAGE AK
99508-2637
US

V. Phone/Fax

Practice location:
  • Phone: 907-350-2326
  • Fax:
Mailing address:
  • Phone: 907-350-2326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: PETER IGWACHO
Title or Position: MANAGING MEMBER
Credential: PHD, CDCS, LSATP,
Phone: 907-350-2326